Unified Prescription Form: NSSF in the Service of Drug Monopolies

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The unified prescription form, which allows pharmacists (under certain conditions) to give patients the choice between a patented medicine and a matching generic one, was a reform measure approved as a law in 2010. This measure helps reduce the extremely high cost of medicines on households, insurers, and the government, but it harms the interests of monopolists dominating the import of medicines. Thus, their representatives and allies at the Doctors Syndicate in Beirut, the National Social Security Fund (NSSF), and even the so-called workers’ representative Ghassan Ghosn, are now obstructing the measure.

No one has had the courage to declare their public opposition to the implementation of Articles 46 and 47 of the Pharmacy Practice Law in Lebanon. All officials, stakeholders, and interest groups on the Lebanese pharmaceutical market have in fact declared the contrary, supporting the bid to adopt a unified prescription form.

These individuals do not have the courage to oppose such administrative measures, even though they do not affect the structure of their interests and only “trim” monopolies and their revenues, while redistributing some. Nevertheless, they sought to use their influence to obstruct it, using superficial arguments to delay the implementation of the law.

The companies controlling the import of medicines stand to lose from the measure, despite the restrictions it imposes on the mechanism of substituting prescribed commercial medicines. To be sure, the law challenges their monopoly and forces them to restructure their relationship with pharmacies, doctors, and administrators, and their shares of market revenues.

Meanwhile, there is a segment of doctor-merchants who are afraid that revenue they are deriving from their ties to patented drug-marketing networks could decline; these drugs are imported by the monopolistic companies and reach patients at many times more the price in the country of origin, according to reports. The drug monopolies and this segment of doctors have closed ranks in an attempt to sustain the fait accompli that has existed since the two articles in question came into force in 2010.

The Doctors Syndicate in Beirut was enlisted in this effort, given its major influence and ability to affect the health minister’s capacity to implement the law — if he was serious about it, of course. Furthermore, the NSSF was used to object to implementing the measure at present.

The NSSF is the largest customer for drug companies, doctors, pharmacies, and various healthcare enterprises. The NSSF covers more than a million consumers of medicines, and it funds the consumption of huge amounts of patented medicines that could otherwise be substituted with cheaper generic ones.

The NSSF stands to gain from implementing the unified prescription in order to keep in check the consumption and cost of medicines, and reduce the deficit in its budget (which is incidentally funded by confiscating the savings of citizens covered by the retirement fund). However, it seems that the influence of drug monopolies and doctors profiting from the situation at the NSSF board is much stronger than the incentive of fulfilling its best interests and achieve savings of up to $200 million annually according to NSSF sources. [I]t seems that the influence of drug monopolies and doctors profiting from the situation at the NSSF board is much stronger than the incentive of fulfilling its best interests and achieve savings of up to $200 million annually.

So instead of searching for ways to facilitate the implementation of the unified prescription, the NSSF board members, including the head of the General Workers Union Ghassan Ghosn, decided to express superficial reservations, which Chairman of the Technical Committee Samir Aoun has cited to block the implementation of the law. This has put the minister of health to the test of whether to back down and retreat or press ahead with the move.

The arguments used to obstruct the law

In the beginning, the argument of the Doctors Syndicate in Beirut was that it could not adhere to the unified prescription form until Article 42 of the Medical Code of the NSSF is amended. The article in question states, “The NSSF only pays the cost of the medicine and pharmaceutical materials prescripted by doctors contracted by the NSSF.”

The text is subject to various interpretations, but it was practically repealed by the law issued in 2010. The 2010 law states, “Regardless of any text, the pharmacist may disburse to a bearer of a medical prescription a generic medicine not mentioned in the prescription, under conditions (...).”

The NSSF board ignored the arguments of the Doctors Syndicate in Beirut for a period of time. It later turned out that the Doctors Syndicate in Tripoli had started implementing the unified prescription, but the NSSF sought to obstruct processing payment of bills related to medicines disbursed according to this prescription form.

The invalid argument prompted the NSSF Technical Committee to cite the provisions of the 2010 law itself to claim that the form used by the Ministry of Health is inconsistent with the law in question, saying that the form does not prevent pharmacists from substituting the prescribed medicine unless the prescribing doctor places a note stating the drugs the doctor refuses to be substituted. Meanwhile, the 2010 law states, “The doctor’s approval must appear on the prescription, by approving or disapproving the substitution in accordance to the form used by the Ministry of Health.” The law also states, “In the event there is no note on the prescription, the pharmacist may not substitute the prescribed medicine.”

The Technical Committee found what it was looking for in the text. Under the pretext of adhering to the literal interpretation of the text, which requires doctors’ approval of substitutions, it rejected the Ministry of Health form as it only requires showing the doctor’s disapproval of substitution to prevent disbursing generic medicines. In other words, the Ministry of Health has come across as more keen on implementing the goals behind the unified prescription than the NSSF itself.

Because of such weak arguments, the conglomerate of interests is using the “golden” argument that works in almost every situation, namely, that the state is incapable of oversight and control. Those opposed to it apparently refuse to subject “consumers” to risks that should otherwise be averted.[T]he conglomerate of interests is using the “golden” argument that works in almost every situation, namely, that the state is incapable of oversight and control.

In their view, the measure could mean opening the market to fake and low-quality cheap drugs, if the government allows a certain margin of competition between patented drugs — which are under strict legal protection under intellectual property laws — and generic medicines, which contain the same active ingredients as the original medicine, and sold under the same brand name or the internationally approved scientific name that is not subject to intellectual property law.

So far, the “conglomerate” has appeared strong and decisive. The former Minister of Health Ali Hassan Khalil was unable to implement the unified prescription form even though he had told the Doctors Syndicate to do so and the form was drafted during his tenure. Current Health Minister Wael Abu Faour is still trying, and is facing massive pressure to retreat. His counterpressure has not pushed the conglomerate to back down. But as a result, the interests of all doctors have been damaged, as Abu Faour resorted to an illegal measure against the doctors when he froze the mechanisms separating payments to doctors from payments to hospitals due on the Ministry of Health, the most important client for doctors and hospitals.

The power of the conglomerate

Some are surprised by the fierce resistance of the conglomerate against the unified prescription form. After all, the new measure is nothing compared to what the late Health Minister Emile Bitar attempted to do.

Back then, the same powerful interest groups rallied against him, pushing him to resign in late 1972. Bitar had proposed a project compelling the NSSF to directly import a number of basic medicines and disburse them to those covered by its program without any intermediaries. Bitar’s argument was the real cost of the medicine had to be known and the cost borne by the NSSF had to be reduced, in light of the huge profits reaped by the monopolistic importers.

At the time, many essential medicines disappeared from the markets. the syndicates representing importers and pharmacists, backed by merchants associations, threatened to go on strike. The president and a number of ministers and MPs put pressure on Bitar to resign, exactly as happened not long ago with former Labor Minister Charbel Nahhas when he proposed a plan for universal healthcare for all Lebanese living in Lebanon.

Abu Faour does not seem to be facing the same kind of risk, especially in light of the political-sectarian protection he enjoys from Druze leader Walid Jumblatt. He is not in an independent position like Bitar and Nahhas, and hence would not press ahead with his plans if Jumblatt decides to stop trying.

Nevertheless, in a meeting he held two days ago with doctors from Rashaya, the Bekaa, and Hasbaya in Rashaya, Abu Faour stated, “The unified prescription form is a key demand that cannot be undone. If there were a single scientific reason to back down, I would have been willing to reconsider [...] but there are only suspicious motives.”

Abu Faour said the Doctors Syndicate has not adhered to the law in question, so far, and therefore, should not demand others to do so. He added, “If we contradict the law, we are doing it for the interest of the poor citizen, while others would be doing it for the sake of suspicious interests.” “The unified prescription form is a key demand that cannot be undone. If there were a single scientific reason to back down, I would have been willing to reconsider [...] but there are only suspicious motives.” — Lebanese Health Minister Wael Abu Faour

The health minister called on doctors to perform their role, and for the debate to take place within their elected syndicate, suggesting there are doctors who support his move in its ranks. He said, “My proof of good faith is that when the Doctors Syndicate in the North implemented the unified prescription form, I cancelled my decision related to separating payments. I am willing to do the same with any doctor who abides by it.” He added, “There are people willing to implement the unified prescription, even if the Syndicate does not abide by it. Doctors have a role to play with the Syndicate, and the reform will not be against but rather in favor of the doctors.”

Al-Akhbar spoke to an official source at the Health Ministry who said that the Doctors Syndicate’s objection to any reform measure by the authorities was nothing new.

In previous years, the source said, the National Bureau for Medicine proposed a project for the rational use of medicine, but pressure brought by importers and the Doctors Syndicate soon forced the ministry to cancel the scheme. The plan could have reduced the total cost of medicines in Lebanon by 30 percent, through direct intervention by the Health Ministry in the import market.

The only success the ministry has achieved in this regard, the source continued, was through the program to improve the cost of (some) medicines for chronic and incurable diseases with support from international organizations like the WHO, which provide the Lebanese government with reasonable prices for some of the medicines.

Why doctors are objecting

Some doctors are afraid of being exposed for the outrageous revenues they make from prescribing medicines. They are not compelled to declare their incomes under a tax system that favors them. But under the unified prescription form, it would be possible to monitor doctors’ revenues especially after computerization of records is completed.

Meanwhile, a number of doctors believe the unified prescription form would allow pharmacists to sell generic medicines with or without prescription (as usually happens when the doctor themselves sell patients commercial medicines that they do not really need). As a result, doctors’ revenues could decrease in favor of pharmacists.

According to the head of the Consumer Association, Dr. Zuhair Barro, the main concern is not about the deals doctors have with drug companies. He says that the entire healthcare sector is controlled by a corrupt network that wants to continue selling expensive commercial drugs.

Barro told Al-Akhbar that the corruption involved includes medical equipment in hospitals and clinics, and contracts between drug companies and doctors. He explained, “The doctors receive percentages from sales of commercial drugs from certain companies, in addition to invitations to international conferences and samples that citizens sometimes pay for, etc.”He [Dr. Zuhair Barro] says that the entire healthcare sector is controlled by a corrupt network that wants to continue selling expensive commercial drugs.

Barro appealed to doctors to try to understand the economic and social importance of the unified prescription form, which he said is an essential part of the battle against corruption in the healthcare sector. The head of the Consumer Association pointed out that involving medical prescriptions in this bickering is aimed at sabotaging the measure.

But not all doctors are in agreement with their colleague, who is active in consumer protection issues. Some have questions about the safety of generic medicines, in light of corruption in the country and the lack of a central laboratory that can carry out tests on the drugs.

Another doctor hinted at the possibility of fraud in medicines. He said, “Nothing is as bad as fake medicine for public health, including food safety.” A colleague of his backs him up and says, “The quality of medicines is more important than pricing and reducing the cost on citizens,” while another asks, “Why should we allow pharmacists to prepare generic medicines? Why not the doctors themselves?”

Barro says that generic medicines have the same composition of patented commercial ones, and hence the same efficacy. Around 92 percent of medicines used in Europe are generic, with pharmacists there recommending generic medicines unless citizens insist on commercial ones. But this is rare, since generic medicines are around 50 percent cheaper than commercial ones.

Many European countries have even stopped manufacturing drugs, and now import generic ones from India, Brazil, and China, the world’s top three makers of generic drugs. Instead, European nations focus on manufacturing drugs for cancer and other serious diseases.

“There is no need to invent any new mechanisms to disburse generic medicines in Lebanon, as we can just follow the European example,” Barro said. However, he stressed the need for serious oversight from the source, and the need for a central laboratory that would handle the monitoring and analysis of the drugs distributed to the markets.

Barro says that in Lebanon, there is a medicines sector parallel to the legitimate one, with many drugs entering Lebanon without going through customs as they are classed as experimental or discount drugs and yet are sold to Lebanese consumers.

A representative of a pharmaceutical company told Al-Akhbar that a large number of drugs imported are not sold in the country of origin. For example, there is the vitamin fresh v, which is sold in Lebanon at a high price, when there are many other locally made vitamins with the same quality and ingredients but at a much lower price.

Interests worth $1.4 billion in the drug market

Many decades ago, drug monopolists were able to expand their network. Some doctors now say publicly they are involved in marketing certain brands and imposing them on their patients, in return for bribes, kickbacks, gifts, and so on. Importers therefore feel the unified prescription form would challenge their monopoly over medicines.

In Lebanon, there are 10 import companies controlling 90 percent of the drugs trade, including four that monopolize 50 percent of the trade. According to the Business Monitor International (BMI), the value of the drugs sector in Lebanon was $1.48 billion in 2014.In Lebanon, there are 10 import companies controlling 90 percent of the drugs trade, including four that monopolize 50 percent of the trade... The value of the drugs sector in Lebanon was $1.48 billion in 2014.

The Syndicate of Pharmaceutical Importers value the trade at $970 million in 2013 based on retail prices, broken down as follows: $745 million sold through pharmacies, $115 million through hospitals, and $115 through public institutions. BMI estimates spending per capita on drugs at around $285.2 per year in 2014, and expects the figure to increase to $292 this year and $345.5 in 2018. BMI attributes this to the market’s excessive reliance on imported drugs and the high number of prescriptions in Lebanon.

Based on BMI’s estimates, prescribed medicines account for 73.8 percent of total drug sales, which it said is a high figure because of the widespread usage of patented drugs. The latter account for 62.6 percent of total spending on prescribed drugs and 46.2 percent on pharmaceutical products.

No quorum at the NSSF board

At the last meeting of the NSSF board, the quorum was broken for the second time when workers’ representatives withdrew (the board consists of 10 workers’ representatives, 10 employers’ representatives, and six representatives of the state). This happened when the discussions hit a dead end, when they were divided over the implementation of the unified prescription form and the amendments of Article 42 of the Medical Code.

According to some board members, the workers’ representatives insisted on the findings of the report prepared by the Technical Committee, which highlights discrepancies between Article 47 of the Pharmaceutical Practice proposing the unified prescription, and the content of the prescription form adopted by the Health Ministry.

This “superficial” argument did not override the discussions over the implications of adopting the prescription form, the main points being:

Some workers’ representatives said we should not risk giving low-quality medicine to those covered by the NSSF for the sake of making savings.

Some members of the board asked for the NSSF to draft its own form, but the law makes this the jurisdiction of the Health Ministry

There is preliminary approval for the NSSF to adopt generic medicines reached by the ministry, which has the technical ability to study and approve this issue.

Some board members expressed concern about fraud that could affect generic medicines.

The law is in force but is not enforced

In March 2010, parliament approved amendments to articles 46 and 47 of the pharmacy practice law in Lebanon. Article I of the law abolishes Article 46 and replaces it with the prescription form adopted by the Ministry of Health in three copies, one for the doctor, one for the pharmacist, and one for the patient, and enumerates a number of conditions and specifications for how doctors and pharmacists deal with prescription.

Article 2 abolishes article 47, and replaces it with the following text:

A - Pharmacists, regardless of any other text, may disburse to bearers of prescription drugs generic brand medicines not mentioned in the prescription under the following conditions:

1. Alternative medicine be included in the list of alternative medicines approved by the Ministry of Public Health in accordance with World Health Organization standards, that:
i) The medicine should contain the same active ingredient in the one mentioned in the prescription and in the same quantities and pharmacological form [...].
ii) The price of sale in Lebanon should be less than the price of sale of the medicine mentioned in the prescription.

2. The patient must agree to the substitution.

3. The doctor’s approval should be stated on the prescription, approving or disapproving the substitution in accordance with the Ministry of Health form. Otherwise, pharmacists may not substitute the medicine.

4. Pharmacists must note [...] the name of the medicine disbursed to the prescription carrier, stating: Substituted in accordance with the new Article 47 of the Pharmacy Practice Law. The insurers, official or private, must approve the substituted medicine and reimburse the cost in accordance to its terms and policies without requiring a prescription for the substitution.”